Category: OCD

CNN featured a nice article on a lesser known subtype of obsessive-compulsive disorder (OCD)–Scrupulosity. This involves religious-themed obsessions, such as fear of blaspheming, fear of going to hell, or a sense that you are inherently bad. Rates of OCD are no higher in more orthodox religious communities, but rates of scrupulosity are, which provides an interesting illustration of how history and environment can influence the particular form that OCD takes.

“Scrupulosity often involves a lot of checking, Abramowitz said. Patients experience distress around the idea that they may have done something wrong or improper, so they may consult the Bible or religious authority figures often to see if they’re doing things right. Consulting people and books isn’t pathological, but in scrupulosity the behavior of checking is excessive compared to other religious people.”

I’m glad to see scrupulosity getting national press, as many people don’t understand it and aren’t aware that it’s an expression of OCD. Click here to read the article.

I think this article offers both a good description of some of the things someone with OCD struggles with, and it illustrates the unfortunate barriers many people face in receiving effective treatment–even in an instutuion such as Yale, and by someone who has educated herself about the type of treatment she needs. She writes:

“Despite knowing exactly what treatment to ask for, it took nearly a year to receive what I hope will be acceptable care at Yale Health.”

Clients regularly ask me for medication recommendations. Because I am not a medication prescriber, I avoid suggesting particular medications or dosages but will talk to them about the pros and cons of trying medication. I recently deepened my knowledge of the pros and cons of medications for OCD when I attended a training though the International OCD Foundation. At this workshop, Dr. Michele Pato, a psychiatrist at the University of Southern California, discussed the use of medications for OCD. Here’s a chart with her suggestions for medications:

Based on Dr. Pato’s advice, here are a few things to consider in choosing a medication:

It’s common to start with a class of antidepressants known as Selective Serotonin Reuptake Inhibitors (SSRI’s). Dr. Pato mentioned she typically starts with Sertraline (known as Zoloft commercially).

The dose needed for OCD is typically higher than the dose used for depression.

If SSRI’s aren’t effective, there’s also evidence that an older Antidepressant called Clomipramine may work. However, it is important to be cautious when taking Clomipramine because—unlike the SSRI’s—it can kill someone when the dosage is too high. Additionally, Clomipramine can interact badly with another SSRI Fluoxetine (Prozac), making it toxic even in smaller doses.

Side effects are common with taking antidepressants, but the side effects often fade over time.

With OCD, it may take 8-12 weeks before there’s any noticeable improvement, so it’s usually a good idea to give the medication enough time to be effective.

There’s a high risk that OCD symptoms will increase when stopping an antidepressant medication, but this risk can be reduced if the individual has had a successful course of CBT + ERP. Dr. Pato mentioned that she frequently tapers people off medication after they successfully complete treatment.

Please note: As I mentioned, I am not a prescriber and am passing on information I learned from a reputable source. As many people with OCD do not have access to a specialist in pharmacology for OCD and often turn to a general practitioner, I offer this is a guide that may be of some use.

Among people with whom I work, a practice that’s grown more common in the last few years but with iffy research support is the addition of an antipsychotic medication when an antidepressant medication doesn’t seem to be working. This is done in an attempt to augment the effect of the antidepressant. The practice concerns me because there’s a lot of research evidence showing that the side effects of antipsychotics can be pretty awful (e.g., weight gain, high blood pressure). It concerned me enough that I wrote an editorial about it that the Oregonian published in 2012.

Now new data has been published that clearly suggests antipsychotics should not be added to antidepressants for people with OCD.

Another study showing that CBT does the best with OCD

A 2013 study examined a group of people with moderate to severe OCD who were already taking an antidepressant. They were divided into three groups.

One group received psychotherapy—cognitive behavioral therapy with ERP.

One group was prescribed an antipsychotic—Risperidone—in addition to the antidepressant.

One group was prescribed a placebo (i.e., inactive) pill.

What did they find?—CBT was much more effective

The results are pretty striking. For those that were given an antipsychotic, only 23% of people showed improvement. This might suggest there is some benefit to adding an antipsychotic; however, this finding is not very impressive because those given the placebo (e.g., sugar pill) showed a 15% improvement. Moreover, the researcher found no statistically significant different between the effectiveness of the antipsychotic and that of the placebo. What this means is that, statistically speaking, the antipsychotic was no better than the placebo; that is, the 23% improvement (i.e., antipsychotic) is not more meaningful than the 15% improvement (i.e., placebo).

By contrast to those who received a pill, 80% of people who received cognitive behavioral therapy with ERP showed improvement! This is 3-4x the rate of improvement compared to those taking an antipsychotic—and without the extensive side effects that are common with antipsychotics.

Antipsychotic medication should not be considered for people with OCD

I think this is an important study because it makes it clear that adding antipsychotic medication is unlikely to really benefit someone with OCD. However, that cognitive behavioral therapy with ERP is more effective than medication for OCD is not a new finding

Obsessive-Compulsive Disorder (OCD) is a serious and disabling problem for many people. Understandably, many people seek out medication to help with this problem, and research is shown that medication can be helpful some people. However, research is also very clear that particular proven forms of psychotherapy work much better than medication for OCD. A newly published review paper provides further evidence that psychotherapy outperforms medication for OCD.

The researchers determined that for OCD, psychotherapy is “clearly more efficacious” than medication. Specifically, psychotherapy was found to be more effective than antidepressants, the most well-research pharmacological treatment for OCD.

What this research adds to what we currently know

This study contributes to a body of literature suggesting that psychotherapy is the treatment of choice for OCD. Previous research has found that medication does not interfere with evidence-based psychotherapy for OCD, but neither does it enhance treatment. In sum, although some people with OCD may benefit from medication, particularly if they are also depressed, medication alone for OCD is a substandard treatment. Cognitive behavior therapy with exposure and response/ritual prevention is the gold standard. There is also newer evidence that Acceptance and Commitment Therapy (ACT), even without ERP, is an effective treatment for OCD.

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